Neurosurgery - Guideline for antimicrobial prophylaxis

Publication: 01/04/2010  
Last review: 28/11/2017  
Next review: 28/11/2020  
Clinical Guideline
CURRENT 
ID: 1676 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for antimicrobial prophylaxis in neurosurgery

  1. Summary table of routine recommendations
  2. Background information
  3. Special antimicrobial prophylaxis recommendations

1. Summary table of routine recommendations

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It is the responsibility of the surgical team to prescribe the prophylactic antibiotics, and the anaesthetist to ensure that they have been given within one hour before incision.

Procedure

Prophylaxis recommended?

Evidence level

Prophylaxis intended to reduce

NNT

Antimicrobial dose/route
<1 hours prior to procedure.

Routine

MRSA risk* or true penicillin allergy

Craniotomy

YES

A (1) (2)

Wound infection

17

Flucloxacillin electronic Medicines Compendium information on Flucloxacillin1g iv single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg iv single dose

CSF shunt insertion

YES

A (1) (4)

Wound and shunt infection

16

Flucloxacillin electronic Medicines Compendium information on Flucloxacillin 1g iv single dose plus Gentamicin 2mg/kg iv single dose (use IBW, see table below)

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg iv single dose plus Gentamicin 2mg/kg iv single dose (use IBW, see table below)

Trans-sphenoidal Pituitary resection

YES

A (1) (2)

Post-operative wound infection and meningitis

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg iv single dose plus Gentamicin 2mg/kg iv single dose (use IBW, see table below)

Penetrating intracranial injury

YES

C (3)

Any infection

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g 8-hourly 5 days

Discuss with Microbiology

Basal skull fracture, CSF leak and CSF fistula

NONE

C (3)

       

See separate guideline for spinal surgery (currently under development

           

* MRSA risk factors
Patients within these categories are considered at increased risk of MRSA infection:

  • Known previous infection or colonisation with MRSA at any site.
  • Resident of a long term care facility (nursing home, residential home or any other long term residential facility) without a negative MRSA screening result.
  • History of inpatient hospital stay within the previous 6 months without a negative MRSA screening result

Calculate the dose

  • Find out the patient's sex, height, weight in kg
  • Read off the patient’s ideal body weight (IBW) for their sex and their height from the appropriate chart below
  • Compare the patient’s actual body weight (ABW) with their ideal body weight (IBW)
  • If the patient’s ABW is less than their IBW (i.e. they are underweight), use their ABW to estimate the gentamicin dose from the charts below
  • If the patient’s ABW is more than, or the same as, their IBW, use their IBW to estimate the gentamicin dose from the charts below

(To convert from imperial weight measurements to metric 1 stone = 6.35kg 1 lb = 0.45kg)

Gentamicin dosing in adult male >16years

Gentamicin dosing in adult female > 16 years

Use height to select
gentamicin dose

IBW
from height
(kg)

Use ABW if
less than IBW (kg)

Gentamicin
dose (mg)

 

Use height to select
gentamicin dose

IBW
from height
(kg)

Use ABW if
less than IBW (kg)

Gentamicin dose (mg)

6’ 3” (1.9m) +

84.5

78 to 82

160

6’ 3” (1.9m) +

79.5

78 to 82

160

6’ 2” (1.88m)

82.2

6’ 2” (1.88m)

77.2

72 to 77

150

6’ 1” (1.85m)

79.9

6’ 1” (1.85m)

74.9

6’ (1.82m)

77.6

72 to 77

150

6’ (1.82m)

72.6

5’ 11” (1.8m)

75.3

5’ 11” (1.8m)

70.3

66 to 71

140

5’ 10” (1.78m)

73

5’ 10” (1.78m)

68

5’ 9” (1.75m)

70.7

66 to 71

140

5’ 9” (1.75m)

65.7

60 to 65

130

5’ 8” (1.72m)

68.4

5’ 8” (1.72m)

63.4

5’ 7” (1.7m)

66.1

5’ 7” (1.7m)

61.1

5’ 6” (1.67m)

63.8

60 to 65

130

5’ 6” (1.67m)

58.8

55 to 59

120

5’ 5” (1.65m)

61.5

5’ 5” (1.65m)

56.5

5’ 4” (1.62m)

59.2

55 to 59

120

5’ 4” (1.62m)

54.2

5’ 3” (1.6m)

56.9

5’ 3” (1.6m)

51.9

49 to 54

100

5’ 2” (1.57m)

54.6

5’ 2” (1.57m)

49.6

5’ 1” (1.55m)

52.3

49 to 54

100

5’ 1” (1.55m)

47.3

43 to 48

90

5’ (1.52m) or under

50

5’ (1.52m) or under

45

2. Background information

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The aim of antimicrobial prophylaxis in neurosurgery is a reduction in surgical site infection. For the most common neurosurgical procedures there is evidence that antimicrobial prophylaxis is of benefit to patients and its use is recommended (1, 2). In the current era of increasing Clostridium difficile infection, Meticillin-resistant Staphylococcus aureus (MRSA) infection and increasing concerns about community-acquired MRSA, reducing the risk of acquisition of these pathogens is a major concern. It is therefore appropriate to limit the use of prophylactic antimicrobials to a single pre-operative dose in most situations.

These guidelines should be applicable to the majority of patients. Where the recommendations in these guidelines do not seem appropriate for a particular patient, the surgeon is advised to discuss the case with a microbiologist.

3. Special antimicrobial prophylaxis recommendations

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Craniotomy
Antibiotic prophylaxis significantly reduces the risk of surgical site infection or sepsis in
non-shunt, clean cranial surgeries. Since Staphylococci and Streptococci remain the main causes of wound infection against which prophylaxis is aimed, Flucloxacillin electronic Medicines Compendium information on Flucloxacillin is recommended, with Teicoplanin electronic Medicines Compendium information on Teicoplanin as an alternative in penicillin allergic patients and those at high risk of MRSA infection. Teicoplanin electronic Medicines Compendium information on Teicoplanin has the advantage of bolus administration, compared to the prolonged intravenous infusion of Vancomycin electronic Medicines Compendium information on Vancomycin that is likely to hinder compliance.

CSF shunt insertion
Intraventricular prophylactic antibiotics have been shown to be associated with a significant reduction in the incidence of shunt infections (4). As antimicrobial impregnated shunts are the current practice at LTHT, a single dose of Flucloxacillin electronic Medicines Compendium information on Flucloxacillin and Gentamicin has been recommended to prevent external infections. Polyvalent Pneumococcal Polysaccharide vaccine has been recommended for all patients with intra-cranial shunts.

Penetrating intracranial injury
Include penetrating missile wounds to the head, both sustained by a civilian or in a military or paramilitary context, accidental or incidental gunshot wounds, penetration by sharp instruments such as knives, screwdrivers, pencils and other wooden objects and other accidental injuries sustained from arrows, darts and pool cues during recreational activities
Level C evidence (3).

Trans-sphenoidal Pituitary surgery
The trans-sphenoidal surgical approach has been the preferred surgical procedure for most
surgical lesions. It has been classified as a clean contaminated procedure since the air filled sphenoidal sinus is crossed, therefore prophylaxis has been recommended.
Postopertaive CSF rhinorrhoea and meningitis have been described as complications with incidence ranging from 0.4 to 9% in various studies (5).

Provenance

Record: 1676
Objective: Reduction in surgical site infection
Clinical condition: Prophylaxis in neurosurgery
Target patient group:
Target professional group(s): Pharmacists
Secondary Care Doctors
Adapted from:

Evidence base

  1. SIGN. Antibiotic Prophylaxis in Surgery. Scottish Intercollegiate Guideline Network   Publication Number 104. Edinburgh; 2008.
  2. Leaper D, Collier M, Evans D, Farrington M, Gibbs E, Gould K, et al. Surgical site infection: prevention and treatment of surgical site infection. In: health NCcfwac, editor.: Royal College of Obstetrics and Gynaecology, Press; 2008.
  3. Bayston R, de Louvois J, Brown EM, Johnston RA, Lees P, Pople IK. Use of antibiotics in penetrating craniocerebral injuries. "Infection in Neurosurgery" Working Party of British Society for Antimicrobial Chemotherapy. Lancet. 2000 May 20;355(9217):1813-7.
  4. Ragel BT, Browd SR, Schmidt RH. Surgical site infection: significant reduction when using intraventricular and systemic antibiotics. Journal of Neurosurgery 2006;105 (2):242-7
  5. Cappabianca P, Cavallo LM, Colao A, De Divitiis E. Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg 2002; 97(2):293-8

Evidence levels
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. LTHT Consensus [no national guidelines exist, guidelines from different learned bodies contradict each other, or no evidence exists]

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

Not supplied

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